Can a patient with a history of tuberculosis (TB) of the knee undergo knee replacement surgery?

Knee Replacement for Previous TB Knee

Yes, patients with a history of tuberculosis of the knee can undergo total knee replacement, but active TB must be definitively ruled out first, and prophylactic anti-tuberculous therapy is strongly recommended perioperatively to prevent reactivation. 1

Pre-Surgical Evaluation Algorithm

Before proceeding with knee replacement in a patient with previous TB knee, the following systematic evaluation is mandatory:

1. Rule Out Active TB Disease

• Obtain chest radiography to identify any evidence of active pulmonary or extrapulmonary TB, even if the patient is asymptomatic 2
• Perform tuberculin skin test (TST) or interferon-gamma release assay (IGRA), with IGRA preferred if the patient has received BCG vaccination 2, 3
  • A reaction ≥5 mm on TST is considered positive in immunosuppressed patients or those with prior TB history 2
• If chest radiograph is abnormal or symptoms are present (unexplained weight loss, night sweats, persistent cough >3 weeks, fever), obtain sputum for acid-fast bacilli smear and culture before proceeding 2
• Any patient with abnormal chest radiograph or previous history of TB should be referred to a TB specialist for assessment before surgery 2

2. Document Previous TB Treatment History

• Verify that the patient received adequate treatment for the original TB knee infection 2
• If previous treatment was inadequate or undocumented, the patient should receive full anti-tuberculous therapy before elective knee replacement 2

Perioperative Anti-Tuberculous Prophylaxis

The critical decision point is whether to provide prophylactic anti-TB medication:

Recommended Prophylaxis Regimen

• Initiate rifampin 10 mg/kg/day (maximum 600 mg) for 4 months starting 2-3 weeks before surgery and continuing for 3 weeks postoperatively at minimum 3, 1
• Alternative: Isoniazid 300 mg daily for 9 months can be used, though rifampin has superior completion rates 2, 3
• The surgery can proceed concomitantly with anti-tuberculous prophylaxis—completion of the full prophylaxis course before surgery is not required 3

Evidence Supporting Prophylaxis

A case series of 6 patients with old TB knee treated with total knee replacement showed that one patient who did not receive prophylaxis developed reactivation of tuberculous arthritis 18 months postoperatively, requiring one year of anti-TB treatment 1. In contrast, patients who received even short-course prophylaxis (2-3 weeks pre-op and 3 weeks post-op) had no reactivations at 6.3 years follow-up 1.

Surgical Considerations

Timing of Surgery

• If active TB is diagnosed, the patient must receive a minimum of 2 months of full multi-drug anti-tuberculous chemotherapy before proceeding with elective knee replacement 2
• For latent TB or adequately treated prior TB, surgery can proceed with concomitant prophylaxis 3, 1

Prosthesis Selection

• Standard total knee replacement prostheses can be used 1, 4
• The type of prosthesis (non-constrained, semi-constrained, or constrained) should be selected based on ligamentous stability and bone quality, not TB history 4

Critical Pitfalls to Avoid

1. Missing Active TB

The most dangerous error is proceeding with surgery in a patient with undiagnosed active TB 5, 6. One case report described a young patient who underwent TKR for what was thought to be osteoarthritis but was actually active TB arthritis, resulting in prosthetic failure and requiring prolonged medical and surgical treatment 5.

2. Inadequate Prophylaxis

Patients who receive no prophylaxis have documented risk of TB reactivation even decades after the original infection 1. The reactivation can occur as late as 14-18 months postoperatively 1, 7.

3. Delayed Diagnosis of Periprosthetic TB

Periprosthetic TB infection is rare but can present years after surgery with nonspecific symptoms (pain, swelling) 7. Standard cultures may be negative, and polymerase chain reaction (PCR) testing may be necessary for diagnosis 7.

Postoperative Management

Monitoring

• Continue anti-tuberculous prophylaxis for the full prescribed duration (4 months for rifampin or 9 months for isoniazid) 2, 3
• Monitor for signs of TB reactivation: persistent pain, swelling, fever, or systemic symptoms during the first 2 years postoperatively 1, 7
• Monthly clinical monitoring for hepatotoxicity if on isoniazid or rifampin, including assessment for nausea, vomiting, abdominal pain, jaundice, or dark urine 2

Salvage Options if TB Reactivates

If periprosthetic TB infection occurs despite prophylaxis:

• Conservative treatment with anti-tuberculous drugs alone is possible if the prosthesis is well-fixed and there is no loosening 7, 6
• One case report documented successful treatment with 12-18 months of anti-TB medication without implant removal 7, 6
• However, most cases require surgical debridement or prosthesis removal with prolonged anti-tuberculous therapy 5, 7

Summary Algorithm

1. Screen all patients with previous TB knee using chest X-ray and TST/IGRA 2
2. If active TB suspected: obtain cultures, refer to TB specialist, treat for minimum 2 months before surgery 2
3. If latent TB or adequately treated prior TB: initiate rifampin 600 mg daily 2-3 weeks pre-op 3, 1
4. Proceed with total knee replacement while continuing prophylaxis 3, 1
5. Complete 4 months total rifampin therapy (or 9 months isoniazid) 2, 3
6. Monitor for reactivation for at least 2 years postoperatively 1, 7